Surviving Sepsis Campaign Guidelines

7/29/2019 Surviving Sepsis Campaign Guidelines

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Management of sepsisSurviving sepsis campaign guidelines

Dr Vincent Ioos

Medical ICU

Pakistan Institute of Medical Sciences


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GRADE system of recommandations

Grades of Recommandation, Assessement,

Development and Evaluation

Quality of evidence: high (grade A),moderate (grade B), low (grade C), or

very low (grade D) Recommandations classified as strong (1)

or weak (2)

The grade of strong or weak is considered ofgreater clinical importance than a difference inletter level of quality of evidence.


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Initial resuscitation (first 6 hrs)

Begin resuscitation immediately in patients with

hypotension or elevated serum lactate >4mmol/L; do not delay pending ICU admission(1C)

Resuscitation goals (1C)

CVP 812 mm Hg

Mean arterial pressure > 65 mm Hg

Urine output > 0.5 mL/kg/hr

Central venous (superior vena cava) oxygensaturation >70% or mixed venous >65%


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Initial resuscitation (first 6 hrs)

If venous oxygen saturation target is not

achieved (2C) Consider further fluid

Transfuse packed red blood cells if required to

hematocrit of30% And / or

Start dobutamine infusion, maximum 20 g/kg/min.


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Diagnosis

Obtain appropriate cultures before starting

antibiotics provided this does not significantlydelay antimicrobial administration (1C) Obtain two or more BCs

One or more BCs should be percutaneous

One BC from each vascular access device in place > 48 hrs

Culture other sites as clinically indicated

Perform imaging studies promptly to confirm

and sample any source of infection, if safe to doso (1C)


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Antibiotic therapy (1)

Begin intravenous antibiotics as early as possible

and always within the first hour of recognizingsevere sepsis (1D) and septic shock (1B)

Broad-spectrum: one or more agents active

against likely bacterial/fungal pathogens andwith good penetration into presumed source (1B)

Reassess antimicrobial regimen daily to optimize

efficacy, prevent resistance, avoid toxicity, andminimize costs (1C)


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Antibiotic therapy (2)

Consider combination therapy inPseudomonas

infections (2D) Consider combination empiric therapy in neutropenic

patients (2D)

Combination therapy 35 days and de-escalationfollowing susceptibilities (2D)

Duration of therapy typically limited to 710 days;longer if response is slow or there are undrainable foci of

infection or immunologic deficiencies (1D) Stop antimicrobial therapy if cause is found to be

noninfectious (1D)


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Source identification and control(1)

A specific anatomic site of infection should be

established as rapidly as possible (1C) and withinfirst 6 hrs of presentation (1D)

Formally evaluate patient for a focus of infectionamenable to source control measures(e.g.abscess drainage, tissue debridement) (1C)

Implement source control measures as soon aspossible following successful initial resuscitation

(1C) (exception: infected pancreatic necrosis,where surgical intervention is best delayed) (2B)


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Source identification and control(2)

Choose source control measure with maximum

efficacy and minimal physiologic upset (1D)

Remove intravascular access devices ifpotentially infected (1C)


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Hemodynamic support andadjunctive therapy

Fluid therapy

Vasopressors

Inotropes

Steroids

Recombinant Human Activated Protein C


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Fluid therapy

Fluid-resuscitate using crystalloids or colloids(1B).

Target a CVP of 8 mm Hg ( 12 mm Hg ifmechanically ventilated) (1C).

Use a fluid challenge technique while associatedwith a hemodynamic improvement (1D).


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Fluid therapy

Give fluid challenges of 1000 mL of crystalloids

or 300500 mL of colloids over 30 mins. Morerapid and larger volumes may be required insepsis-induced tissue hypoperfusion (1D).

Rate of fluid administration should be reduced ifcardiac filling pressures increase without

concurrent hemodynamic improvement (1D).


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Vasopressors (1)

Maintain MAP 65 mm Hg (1C)

Norepinephrine and dopamine centrally administeredare the initial vasopressors of choice (1C)

Epinephrine, phenylephrine, or vasopressin should notbe administered as the initial vasopressor in septic shock(2C). Vasopressin 0.03 units/min may be subsequently

added to norepinephrine with anticipation of an effectequivalent to norepinephrine alone


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Vasopressors (2)

Use epinephrine as the first alternative agent inseptic shock when blood pressure is poorlyresponsive to norepinephrine or dopamine (2B).

Do not use low-dose dopamine for renalprotection (1A).

In patients requiring vasopressors, insert anarterial catheter as soon as practical (1D).

(1A)


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Inotropes

Use dobutamine in patients with myocardialdysfunction as supported by elevated cardiacfilling pressures and low cardiac output (1C).

Do not increase cardiac index to predeterminedsupranormal levels (1B).


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Sterods (1)

Consider intravenous hydrocortisone for adult septic

shock when hypotension responds poorly to adequatefluid resuscitation and vasopressors (2C)

ACTH stimulation test is not recommended to identify

the subset of adults with septic shock who should receivehydrocortisone (2B)

Hydrocortisone is preferred to dexamethasone (2B)


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Sterods (2)

Fludrocortisone (50 g orally once a day) may beincluded if an alternative to hydrocortisone is being usedthat lacks significant mineralocorticoid activity.Fludrocortisone is optional if hydrocortisone is used(2C).

Steroid therapy may be weaned once vasopressors are nolonger required (2D)

Hydrocortisone dose should be < 300 mg/day (1A)

Do not use corticosteroids to treat sepsis in the absenceof shock unless the patients endocrine or corticosteroidhistory warrants it (1D).


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Recombinant humanactivated protein C

Consider rhAPC in adult patients with sepsis-induced organ dysfunction with clinicalassessment of high risk of death (typicallyAPACHE II 25 or multiple organ failure) ifthere are no contraindications (2B, 2C forpostoperative patients).

Adult patients with severe sepsis and low risk of

death (typically, APACHE II 20 or one organfailure) should not receive rhAPC (1A)


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Other supportive therapyof severe sepsis

Blood product administration Mechanical ventilation of sepsis-induced ALI/ARDS

Sedation, analgesia, and neuromuscular blockade insepsis

Glucose control Renal replacement

Bicarbonate therapy

Deep vein thrombosis prophylaxis

Stress ulcer prophylaxis

Consideration for limitation of support


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Blood transfusion (1)

Give red blood cells when hemoglobin decreases to < 7.0

g/dL (


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Blood transfusion (2)

Do not use antithrombin therapy (1B)

Administer platelets when (2D)

Counts are _5000/mm3 regardless ofbleeding

Counts are 500030,000/mm3 and there issignificant bleeding risk

Higher platelet counts (_50,000/mm3) arerequired for surgery or invasive procedures


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Mechanical ventilation for sepsisinduced ALI/ARDS (1)

Target a tidal volume of 6 mL/kg (predicted) bodyweight in patients with ALI/ARDS (1B)

Target an initial upper limit plateau pressure


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Mechanical ventilation for sepsisinduced ALI/ARDS (2) Consider using the prone position for ARDS patients

requiring potentially injurious levels of FIO2 or plateaupressure, provided they are not put at risk frompositional changes (2C)

Maintain mechanically ventilated patients in asemirecumbent position (head of the bed raised to 45)unless contraindicated (1B), between 30 and 45 (2C)

Noninvasive ventilation may be considered in theminority of ALI/ARDS patients with mild to moderatehypoxemic respiratory failure. The patients need to behemodynamically stable, comfortable, easily arousable,able to protect/clear their airway, and expected to

recover ra idl (2B).


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Mechanical ventilation for sepsisinduced ALI/ARDS (3)

Use a weaning protocol and an SBT regularly to evaluatethe potential for discontinuing mechanical ventilation(1A)

Do not use a pulmonary artery catheter for the routinemonitoring of patients with ALI/ARDS (1A)

Use a conservative fluid strategy for patients withestablished ALI who do not have evidence of tissuehypoperfusion (1C)


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Sedation, analgesia, andneuromuscular blockade in sepsis

Use sedation protocols with a sedation goal for criticallyill mechanically ventilated patients (1B)

Use either intermittent bolus sedation or continuous

infusion sedation to predetermined end points (sedationscales), with daily interruption/lightening to produceawakening. Re-titrate if necessary (1B)

Avoid neuromuscular blockers where possible. Monitordepth of block with train-of-four when using continuousinfusions (1B)


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Glucose control Use intravenous insulin to control hyperglycemia in

patients with severe sepsis following stabilization in theICU (1B)

Aim to keep blood glucose 150 mg/dL (8.3 mmol/L)using a validated protocol for insulin dose adjustment(2C)

Provide a glucose calorie source and monitor bloodglucose values every 12 hrs (4 hrs when stable) inpatients receiving intravenous insulin (1C)

Interpret with caution low glucose levels obtained withpoint of care testing, as these techniques mayoverestimate arterial blood or plasma glucose values (1B)


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Renal replacement

Intermittent hemodialysis and CVVH are

considered equivalent (2B).

CVVH offers easier management inhemodynamically unstable patients (2D).


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Bicarbonate therapy

Do not use bicarbonate therapy for the purposeof improving hemodynamics or reducingvasopressor requirements when treating

hypoperfusion induced lactic acidemia with pH

7.15 (1B)


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Deep vein thrombosis prophylaxis

Use either low-dose UFH or LMWH, unless

contraindicated (1A)

Use a mechanical prophylactic device, such ascompression stockings or an intermittent compressiondevice, when heparin is contraindicated (1A)

Use a combination of pharmacologic and mechanicaltherapy for patients who are at very high risk for deep

vein thrombosis (2C)

In patients at very high risk, LMWH should be usedrather than UFH (2C)


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Stress ulcer prophylaxis

Provide stress ulcer prophylaxis using H2blocker (1A) or proton pump inhibitor (1B).

Benefits of prevention of upper gastrointestinalbleed must be weighed against the potential fordevelopment of ventilator-acquired pneumonia


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Considerationfor limitation of support

Discuss advance care planning with patients andfamilies. Describe likely outcomes and setrealistic expectations (1D)

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Surviving Sepsis Campaign Guidelines